When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

Correct Answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.

Correct Answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

Correct Answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

Correct Answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

Correct Answer: C

Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.

Correct Answer: C

Rationale: In a mass casualty situation, a client with hypovolemic shock should be the priority as they require immediate intervention to restore fluid volume and prevent further deterioration. Hypovolemic shock can lead to organ failure and death if not addressed promptly. While clients with other severe conditions like massive head trauma, full-thickness burns, or an open fracture also need urgent care, hypovolemic shock directly threatens the client's life due to inadequate circulating blood volume. Therefore, stabilizing the client with indications of hypovolemic shock takes precedence over others in this scenario.

Correct Answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

Correct Answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

Correct Answer: C

Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.